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Chapter 10: Thromboembolic Disease

A 45-year-old man is complaining of shortness of breath after travelling to Asia for business. He is accompanied by his wife. His blood pressure (BP) is 120/60 mmHg, his heart rate (HR) is 90 beats/min, his respiratory rate (RR) is 18 breaths/min, his O2 sat is 98% on room air, and his physical examination is otherwise unremarkable except for a swollen right leg. His labs show the following:

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White blood cells 10 × 103L
Hemoglobin 14 g/dL
Hematocrit 45%
Platelets 300 × 103L
Sodium 145 mEq/L
Potassium 4 mEq/L
Magnesium 2 mEq/L
Chloride 109 mEq/L
Carbon dioxide 28 mEq/L
Blood urea nitrogen 20 mg/dL
Creatinine 0.8 mg/dL
Lactic acid 0.8 mmol/L
B-type natriuretic peptide 40 pg/mL
Troponin 0.0 ng/mL

Ultrasound of his right lower leg is negative for deep vein thrombosis. The CTA of his chest shows a PE in the right lower lobe. His echocardiogram shows no wall motion abnormalities. His ejection fraction (EF) is greater than 60% and he has no diastolic dysfunction. His right ventricular systolic pressure (RVSP) is 15 mmHg. His right ventricle is not enlarged. Where should the patient be treated?

A. Outpatient

B. Medical-surgical

C. Progressive care unit (PCU)

D. Intensive care unit (ICU)

A. Outpatient

Treatment for acute pulmonary embolism with novel oral anticoagulants (NOAC) does not require hospital admission. Candidates for outpatient PE treatment include (1) hemodynamic stability with good cardiopulmonary reserve; (2) no contraindications, such as recent bleed, severe renal disease, severe liver disease, and/or platelet count of less than 70,000/mm3; (3) compliance to medications; and (4) a patient who feels well enough to be treated at home. Hospitalization, whether medical surgery, progressive care unit, or intensive care unit, is not necessary.

Stratification can be performed further with the pulmonary embolism severity index as seen in Table 10-5A and Table 10-5B.

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Table 10-5A. Pulmonary Embolism Severity Index
Pulmonary Embolism Severity Index 30-Day Mortality
Predictors Points
Age Age, in years  
AMS 60  
SBP < 100 mmHg 30  
Cancer 30  
Arterial O2 sat < 90% 20  
Temp < 36°C 20  
RR ≥ 30 20  
HR ≥ 110 bpm 20  
Male 10  
History of heart failure 10  
History of chronic lung disease 10  
Classifications    
Class I (very low risk) ≤ 65 0 –1.6%
Class II (low risk) 66–85 1.7–3.5%
Class III ...

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